1. First Name, Middle Name, Last Name of Insured
5. Date of Birth (Month, Day, Year)
8. Enter the amount, plan, and premium of the insurance for which you are applying. (See Pamphlet 29-9 - Service-Disabled Veterans
Insurance Information and Premium Rates)
A. Amount of Insurance
9. Check the method showing how you wish to pay for this insurance
6. Day Time Telephone Number (Include Area Code)
10. Beneficiary Designation and Optional Settlement
Privacy Act Notice: VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of 1974 or Title 38, Code
of Federal Regulations 1.576 for routine uses identified in the VA system of records, 36VA00, Veterans and Armed Forces Personnel U.S. Government Life Insurance Records -
VA, published in the Federal Register. Your obligation to respond is voluntary, but your failure to provide us the information could impede processing. Giving us your SSN
account information is voluntary. Refusal to provide your SSN by itself will not result in the denial of benefits. VA will not deny an individual benefits for refusing to provide
his or her SSN unless the disclosure of the SSN is required by a Federal Statute of law in effect prior to January 1, 1975, and still in effect. The responses you submit are
considered confidential (38. U.S.C. 5701).
Respondent Burden: We need this information to establish your eligibility for VA Insurance benefits (38 U.S.C. 1922). Title 38, United States Code, allows us to ask for this
information. We estimate that you will need an average of 20 minutes to review the instructions, find the information, and complete this form. VA cannot conduct or sponsor a
collection of information unless a valid OMB control number is displayed. You are not required to respond to a collection of information if this number is not displayed. Valid
OMB control numbers can be located on the OMB Internet page at www.reginfo.gov/public/do/PRAMain. If desired, you can call 1-800-827-1000 to get information on where
to send comments or suggestions about this form.
Complete Name and Address of Each Principal and
Contingent Beneficiary (For married women, enter
her own first and middle names. For example,
Mary Rose Smith, not Mrs. John Smith)
Beneficiary's Social
Security Number (If known.
This is not required for this
designation be valid)
Relationship of the
beneficiary to you
Share to be paid to each
beneficiary (Use $ amounts,
%, or fractions)
Payment Option for Each
Beneficiary (See
pamphlet for more
information)
Or to survivors
Contingent (Person(s) who get the proceeds if
the principal beneficiary(ies) die before the
insured. If none, write "NONE"
7. Email Address
2. Mailing Address for Insurance Purposes
11. This beneficiary change cancels all prior Beneficiary and Option selections and will apply to all my Government Life Insurance policies
under my file number unless the box is checked.
12. Signature of Applicant (Do NOT print, sign in ink)
Lump Sum
Lump Sum
Lump Sum
Lump Sum
Lump Sum
Lump Sum
Lump Sum
Lump Sum
3. Insurance File Number
4. Social Security Number
B. Plan of Insurance C. Monthly Premium
13. Date
A. I want to pay premiums by a monthly deduction from my VA Compensation or Pension. (We will start the deduction for you if
the insurance is approved)
B. I want to pay premiums by a monthly allotment from my military service/retirement pay. (We will start the allotment for you if
the insurance is approved)
C. I want VA to automatically withdraw the premium each month from my bank account (VA MATIC) (Send your first payment
with this application)
D. I will send premiums directly to VA as follows: (Send your first payment with this application)
Monthly
Quarterly Semi-Annually
Annually
I would like this change to apply only to my Supplemental Service-Disabled Insurance policy. Please keep the existing beneficiary
designation on all other insurance policies under the above file number.
VA FORM 29-0188, MAR 2017
